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Record Keeping and Documentation

CPDTime.
7m of CPD
Good record keeping is a fundamental part of delivering safe patient care. An accurate written record detailing all aspects of patient monitoring is important because it contributes to the circulation of information amongst the different teams involved in the patient's treatment or care.

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  • CPDTime.
    7m of CPD
  • Article
  • 3 Assessment Questions

What is this article about?

Good record keeping is a fundamental part of delivering safe patient care. An accurate written record detailing all aspects of patient monitoring is important, not only because it forms an integral part of the of the provision of care or nursing management of the patient, but because it also contributes to the circulation of information amongst the different teams involved in the patient's treatment or care. In a legal sense, documentation and record keeping is also there for the protection of the nurse or healthcare professional.

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Contents

Test Your Knowledge

  • 3 Assessment Questions

Document and reflect on your learning

  • CPDTime.
    7m of CPD

Meet the educator

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Lydia Nabwami
Lydia Nabwami is registered nurse who has worked in various healthcare settings including cardiac ward, cardiac critical care unit (ITU), general ITU, A&E department, nursing homes and community nursing. She uses her experience as a RN to write well-researched content that helps to attract and motivate audiences. Lydia is also a freelance writer for hire with specialisation in health writing and has helped numerous companies with their content needs. Her work has appeared on sites such as Caring Village, Reachout, Lisa Nelson RD and more. When she isn’t writing, you can find her listening to motivational speeches, keeping active or playing with her two daughters. Contact Lydia or visit her website at Lnwritingservices.co.uk for more information on her services.
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What do others think?

1226 reviews by Ausmed Learners
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Portrait of Jacqueline Coatsworth
Jacqueline Coatsworth
12 Jan 2021
An easily accessible resource
Portrait of Veronica Barry
Veronica Barry
11 Jan 2021
Good reflection of the need for legal and care focused documentation no matter whree a nurse practices
JV
Jennelyn Valeros
09 Oct 2021
Great information
TS
Teena Steenis
01 Mar 2021
Great overview and refresher of the importance of documentation
ML
Michelle Lawrence
21 Sep 2020
Very helpful when assisting with students learning needs.
JP
jane prezma
06 Mar 2021
Reinforces the need for timely and comprehensive documentation of the care and condition of the patient in any of the settings.
DG
Deirdre Gillick
25 Nov 2019
Very good paper on important of report writing
YS
Yongqi Shang
09 Jul 2021
Good
PD
Patricia Drew
13 May 2020
This was quick and easy.Very straight forward
VS
Vanessa Shearer
07 May 2021
This resource is a valuable tool for nurses to reinforce the importance of accurate and clear documentation and communication.
4.4 / 5
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